Every student that pays attention online is constantly getting punched in the face with paradigm shifting information. Hot topics like pain neuroscience, PT role in prevention/ population health, manual therapy…the list goes on. Every time I think I learn something solid, I see a blog post that blows it up. Every time I think I have a grasp on something it seems to slip out of my hands, because “it doesn’t work or there are better ways to go about this.” It can be ultra frustrating as a student because at the end of the day you have to do something with your patients…I expect that this is how I am going to feel for a while, or maybe the entire time I am practicing PT.
My most recent paradigm shift has been a really radical one for me. It is centered on the idea of manual therapy or more specifically tissue specificity in manual therapy. Since the beginning of PT school, when I was spending HOURS learning anatomy, I always thought anatomy and tissue location, type and function were the most important things I could know as a PT. It’s like trying to write a novel without knowing english, it is the language of medicine. Scapulae, transverse processes, ligamentum flavum, multifidi…I continued to pound these things into my head because I wanted to be good. Then we moved from the basic sciences to more clinically relevant courses, like our movement science classes and our musculoskeletal series. During these classes, the clinical side of things built right on top of the anatomy. “If you have an increased dynamic Q angle, it loads the lateral compartment, the ligamentous structures of the knee and so on which causes injury and ultimately pain.” “Mobilize this, move that, stretch this, strengthen that.” It all was making sense. We went on further, more conceptual now. Find the dysfunctions, find the “pain generators”, find contributing factors, concordant signs….again it all made sense. When things hurt, we do a bunch of tests clinically and figure out what the thing is that is messed up and is causing the pain and we fix it…yeah go us!
Well, then I got into the clinic and then I started reading the literature.
What I kept seeing frustrated me…manual therapy isn’t doing what you think it is, connective tissue is too strong to change, all these effects are transient, palpation is awful and unreliable and on and on and on. Well then…looks like all the things I know are wrong…cool beans. So what the heck do I do with people? Well the only thing that is clearly good for everybody is strengthening the crap out of everything, so that’s good. But there’s no system to that, there’s no structure. The people saying that nothing I know works are the ones who have been practicing for 10 years, went through all the additional training in the stuff I know and are NOW saying that. They have a framework. I don’t. So I’m a little lost at this point. Where do I go to figure this stuff out? Now that boards are over (hopefully) how can I get effective in the clinic and not feel like I am maxing out my brain every moment of every day trying to treat “regular” patients.
Enter MDT.
I hated MDT when we learned about it in school. We had one lab on it and we talked about derangements, dysfunctions and postures…all of which were words that I had either not heard of or had very different meanings to me than what they mean to MDT people. We talked about how extension is great for disc patients, practice prone press ups, mentioned that centralization was a thing and we were done…Well that was dumb…they didn’t even tell us how centralization works, or what all this is doing to the specific tissues. I immediately casted it out of my brain and my framework, back to tissues, manual therapy and the sexy cool manipulations and things. Fast forward 2 years, to now. Centralization, directional preference and classification are all part of the clinical practice guideline for treating LBP. Which by the way doesn’t mention a whole lot about tissue specific manual therapy.
My brain is now exploding. My biases and my “system” are being challenged and I don’t like it at all, but I want to know more and be good, so I press on (pun intended). I reach out all the MDT people I know and grill them with questions, Allan Besselink, David Grigsby, Keaton Ray, and some others and they continually impress me. Everything I ask them fits into the system. Turns out MDT doesn’t suck… It is simple. And it is based on movement. And I don’t have to have “good hands” and I don’t have to know if it’s a facet capsule synovitis or a facet joint arthrosis…as much as I freakin want to.
The thing that I thought was a dumb and poorly explained exercise routine turns out to be the best system for evaluating and treatment people without fumbling around with tissue diagnosis. Now, I understand that there is no perfect system out there, I know that MDT has its flaws, like the disc material being pushed here and there, BUT it is a system and a reliably effective system nonetheless that as a new grad I need.
I welcome comments and papers and direction on this topic because ultimately I want to get better and I hope you do too. This is not a dead topic for me…it is still an active struggle and I’m sure it will be for some time but I think the struggle is good.
F3 Physical Therapy 